Health care seeking behaviour towards cervical cancer screening among women aged 30–49 years in Arbaminch town, Southern Ethiopia, 2023

Background Cervical cancer is a preventable disease. However, it remains the commonest and deadly cancer in women worldwide. Health care seeking behaviour is not well studied in Ethiopia even though it is crucial in averting cervical cancer by maximizing cervical cancer screening utilization. Therefore, this study amid to assess health care seeking behaviour towards cervical cancer screening and its associated factors among women aged 30–49 years in Arba Minch town, Southern Ethiopia, 2023. Methods A community-based cross-sectional study design was conducted on 414 women who are in the age range of 30–49 in Arba Minch town from January 2-February20, 2023. Study participants were selected by a simple random sampling technique from all kebeles and data were collected using pretested interviewer administered questionnaires. SPSS version 27 was used to conduct binary and multivariable logistic regression analysis. Socio-demographic characteristics of the respondents were described using descriptive statistics. Furthermore, binary and multivariable logistic regression analyses were made to find the factors associated with health care seeking behaviour. Variables with a p-value less than 0.25 on binary logistic regression were selected for multivariable logistic regression. Variables with a p-value < 0.05 were considered statistically significant. The reliability and internal consistency of the constructs of health belief model were calculated independently using Cronbach’s alpha. Result The prevalence of health care seeking behaviour towards cervical cancer screening was 197(47.6%) [95%CI: 42.7-52.5%]. Respondents’ good knowledge [AOR = 1.55, 95%CI: 1.01–2.39], positive perceived susceptibility [AOR = 3.63, 95%CI: 2.06–6.42], positive perceived severity [AOR = 2.65, 95%CI: 1.71–4.09], positive perceived benefits [AOR = 4.85, 95%CI: 2.92–7.87] were significantly associated with health seeking behaviour. Conclusion The prevalence of health care seeking behaviour towards cervical cancer screening is low in this study. To maximize the health care seeking behavior of women, further acting on perceived susceptibility, respondents’ knowledge, perceived severity, and perceived benefit of the woman are crucial.


Background
Globally, cervical cancer is the fourth most common cancer in women with an expected 604, 000 new occurrences and 342, 000 deaths in the year 2020 [1].. In Africa, cervical cancer is the leading cause of cancer death amongst women, with an estimated 117,316 new cervical cancer cases each year, making cervical cancer the 2nd leading cause of female cancer and the 2nd most common female cancer among women aged 15 to 44 years in the continent [2].Africa carries the greatest burden, with 24.55% of the global mortality from cervical cancer [3].Eastern Africa alone shares the highest burden with an estimated 54,560 annual number of new cervical cancer cases [2].
According to Information Centre on HPV and Cancer (estimation for 2020), about 7,445 new cervical cancer cases and 5335 deaths occur each year in Ethiopia, making cervical cancer the 2nd top cause of female cancer in the country [4].
Human Papilloma Virus (HPV), sexual history, smoking, Chlamydia infection, birth control pills, having multiple full-term pregnancies, young age at first full-term pregnancy and having a weakened immune system are some of the identified risk factors of cervical cancer [5].Among the risk factors listed majority of cervical cancer is caused by HPV.Currently, around 13 different types of HPV have been identified based on their potential to be cancerous [6].Among high grade cervical pre-cancers, HPV16 and 18 are responsible for nearly 70% of cervical cancer cases [2].
Health care seeking behavior toward cervical cancer gives a chance for the application of both primary and secondary prevention strategies for wide-ranging prevention and control strategies of cervical cancer [7].The Health Belief Model (HBM) emphases on the causes of health-related behaviors, with factors consisting of perceived susceptibility and severity of a health problem, perceived benefits and barriers of conducting health-related behaviors, cues to action, and other sociodemographic factors (Fig. 1) [8].According to the HBM, women are more likely to engage in health care seeking behavior if their perceptions of susceptibility and seriousness are high, the barriers to do such behaviors are low, and the benefits of engaging in such health behaviors are substantial [9].According to previous studies, factors associated with poor health care seeking behavior were poor knowledge, not ever received information, education level of the respondents, and not actively searching information [7,10].
According to the literature, factors associated with poor health care seeking behavior were poor knowledge, Fig. 1 Diagram Illustrating the health belief model [11] not ever received information, education level of the respondents, and not actively searching information [7,10].
To significantly drop the incidence and mortality caused by cervical cancer, by maximizing the cervical cancer screening service utilization, such barriers must be addressed.Thus, awareness should be created, and there must be effective screening and prevention services that facilitate early detection and treatment.To address this issue, Behavioral change communication (BCC) is one strategy used to impact social norms, promote behaviour change, and raise awareness of cervical cancer prevention in a particular group of people or subpopulations according to Federal Democratic Republic of Ethiopia Ministry of Health guideline for cervical cancer prevention and control [12,13].There is insufficient data on health care seeking behaviour for the prevention and control of cervical cancer in Ethiopia according to what is specified in the national strategic Plan for the prevention and control of chronic diseases [13].Furthermore, there are no community based studies conducted so far on health care seeking behaviour towards cervical cancer screening among women aged 30-49 years in the country.Therefore, this study aims to assess health seeking behavior towards cervical cancer screening and associated factors among women aged 30-49 years using the HBM as a guiding theoretical framework in Arba Minch town, Southern Ethiopia, 2023.

Study area and period
The study was conducted in Arba Minch town, which is located about 495 km south of Addis Ababa, the capital city of Ethiopia, and 275 km from Hawassa, the capital of Southern Nations and Nationalities People region.The total number of population of Arba Minch town in the year 2014E.C is 123,446 of which around 61,970 (50.2%) are females.The number of women in the age range of 30-49 in the town is 11,898.There are twelve kebeles (the smallest administrative units in the country) in the town and there are a total of 4 health facilities (1 general hospital, 1 primary hospital, and two health centers).The data was collected from January 2-February20, 2023.

Study design
A community-based cross-sectional study design was conducted.

Study participants
All 30-49 years women living in Arba Minch town were the source population and women who had the chance of being randomly selected from the source population at a household level were the study population.All 30-49 year women (including pregnant women) who had lived in the study area for at least 6 months were included in the current study whereas, women who were already screened and diagnosed for cervical cancer and those women who have had total hysterectomy were excluded from this study.

Sample size
The sample size in the current study was calculated using a single population proportion formula, with an assumption of margin of error 5%, 95% confidence level, and we used a 50% proportion of health care seeking behavior since there is no previous study on the topic among women aged 30-49 years.

Sampling techniques
Simple random sampling method was employed to select the study subjects.There are a total of twelve kebeles in Arba Minch town.List of households with women of 30-49 age were obtained from health extension workers of the respective kebeles.Samples were allocated to each kebele proportionally to their size.Then, the sample was drawn using a simple random sampling technique via computer-generated random numbers.Randomly selected households with eligible women were traced using their house numbers and health extension workers were used as guidance.Lottery method was used when more than one eligible woman were encountered in the household.(Fig. 2)

Data collection and measurement
The data was collected by face-to-face interview using pretested structured questionnaires using the kobo tool box mobile application.The questionnaire was prepared in English and then translated into Amharic and back to English for checking language consistency by different person with an excellent metalinguistic skill who can understand the context.Two days of training was given for two BSc midwifes.Before data collection, pre-test was conducted on 5% of the computed sample at Chencha town.Depending on the feedback obtained from the pretest result, necessary correction and arrangement of sensitive questions were made to improve the clarity, understandability, and simplicity.The collected data was checked for completeness and consistency by the investigator.Using Cronbach's alpha, the reliability and internal consistency of the HBM constructs were calculated independently.Perceived susceptibility was measured by 3 items with Cronbach alpha of 0.81, perceived severity was measured with 6 items with Cronbach alpha of 0.83, while perceived benefit was measured with 4 items which gave Cronbach alpha of 0.84 and perceived barriers were measured with 6 items with Cronbach alpha of 0.89.The collected data was checked for completeness and consistency by the investigator.
The questionnaire was developed based on the modified and adapted Champion's health belief model scales [14,15] and review of other literatures [16][17][18][19][20][21].The questionnaires have the following parts: The socio-demographic characteristics consisted of age, occupation, educational background, religion, marital status, and monthly income.
• Knowledge about cervical cancer and screening: A total of 11 items were used to assess the participant's knowledge and correct answers were categorized as 1 and incorrect answers were categorized as 0. The maximum point value was 11 and the minimum point was 0. Then, the respondent's knowledge was categorized either in to good knowledge (those who scored above the mean) and poor knowledge (those who scored below the mean) based on the cumulative mean score of participants' knowledge on cervical cancer [18].Cues to action: Strategy to activate the decision-making process to get screened for cervical cancer and was measured using 3 items and participants who scored mean and above were considered as having positive cues to action [15].Perceived severity, susceptibility, benefit, barrier, and self-efficacy were assessed using the Likert scale (1 = strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = strongly agree).Mean scores were computed for each construct and dichotomized into high/positive and low/ negative [14,15,22].
Health care seeking behavior: it was measured using four items with five points of Likert scale and based on the mean score; women were classified in to having health seeking behavior and not having health seeking behavior [7].

Data processing and analysis
The collected data was first cleaned and exported from kobo collect to SPSS Version 27.0 for further management and analysis.Descriptive statistics was computed and described using tables, figures, and charts.Binary logistic regression analysis was used to see the independent effect of predictors on health care seeking behavior.Those values with a P value < 0.25 during Bivariable analysis were retained for multivariable analysis.Odds ratio (ORs) with 95% corresponding confidence intervals (CIs) was calculated to measure the strength of the association between explanatory variables and the outcome variable.The statistical significance was considered at P-value less than 5%.Hosmer and Lemeshow model fitness test was used to test the model fitness and the value was 0.6.Multicollinearity was determined by variable inflation factor and no multicollinearity was found among the constructs of the HBM.Finally, the findings were presented using texts, tables, graphs, and charts.

Socio demographic characteristics of participants
A total of 414 women participated in the study, giving a response rate of 98%.Majority 298 (72%) of the study participants were between the age categories of 30-39.The mean and standard deviation of the age of the study participants were 37.6 ± 5.3 years.Majority 347(83.8%) of the respondents were married.Regarding the educational status of the study participants, majority 228(55.1%) of the study participants had no formal education and only 74(17.9%) of the respondents were college and above graduates.(Table 1)

Participants knowledge regarding cervical cancer and its prevention
In this study, it were found that the majority, 329(79.5%) of the study participants had heard about cervical cancer.Of those who had heard about cervical cancer, the majority, 171(43.3%)had heard about cervical cancer  3)

Constructs of the health belief model
About 274(66.2%) of the study participants had a positive perceived benefit towards cervical cancer screening.Half 207(50%) of the respondents had a positive perceived severity towards cervical cancer screening.Only eightythree (20%) of the respondents had a positive perceived susceptibility towards cervical cancer screening.(Table 3)

Factors associated with health care seeking behavior
In the current study, the respondent's good knowledge, positive perceived susceptibility, positive perceived severity, and positive perceived benefit were factors associated with good health care seeking behavior towards cervical cancer screening, whereas variables like perceived selfefficacy, perceived barriers and cues to action were not significantly associated with health care seeking behaviour.(Table 4)

Discussion
This study determined the level of health care seeking behavior towards cervical cancer screening and associated factors among women in 30-49years.In the current study, 197(47.6%)[95%CI: 42.7-52.5%] of women had health care seeking behavior towards cervical cancer screening.This finding is higher than a study conducted in Hossana town, Southern Ethiopia, which showed only 14.2% of the participants had health care seeking behavior towards cervical cancer screening.This might be due to differences in the tools used in the current study and the increased level of awareness of the women about cervical cancer screening from time to time [7].The present study is also higher than the study conducted in Nepal which showed only 18.3% of the participants had health seeking behavior towards cervical cancer screening.This could be due to the difference in the sample size and population characteristics of the two countries [10].However, the current finding is lower than the previous study conducted in Arbaminch town on the utilization of cervical cancer screening which showed 71.5% of the study participants had an intention for cervical cancer screening [23].In the current study, those participants who had good knowledge towards cervical cancer screening were 1.55 times more likely to have good health care seeking behavior towards cervical cancer screening than their counter parts (AOR = 1.55, 95%CI = 1.01-2.39).The   finding of this study is consistent with studies conducted in Kenya, Johannesburg, Mekelle, and Jimma, Ethiopia [20,24]- [26].This might be due to the different activities that have been undertaken to increase the utilization of cervical cancer screening.For instance, health education by health care providers, campaigns prepared by health care providers and university students during team training programs about cervical cancer and its preventive methods, which in turn will result in modified attitudes and changed behavior.
Regarding the perceived susceptibility of women towards cervical cancer screening, this study revealed that those women who had positive perceived susceptibility were 3.63 more likely to have health care seeking behavior towards cervical cancer screening than their counter parts (AOR = 3.63, 95%CI = 2.06-6.42).This finding is in line with the studies conducted in Jimma and Mekelle Ethiopia [19,25].This might be due to these women who have had awareness about cervical cancer and perceived as they are at risk of getting cervical cancer are more likely to undergo cervical cancer screening to protect themselves.
Perceived benefits are the positive outcomes a woman believes will result if they decide to take action to reduce and/or prevent cervical cancer.This study revealed that those women who had positive perceived benefit towards cervical cancer screening were 4.85 times more likely to have health care seeking behavior towards cervical cancer screening than their counter parts (AOR = 4.85, 95%CI = 2.92-7.87).This finding is supported by study conducted in Bishoftu [17].This might be due to an increase in the level of awareness of the benefits of cervical screening among women from time to time.However, studies conducted in Botswana, Nepal, and Jimma revealed that cervical cancer screening behavior of the respondents was independent of the perceived benefits of cervical cancer [10,19,21].
The result shows that study participants who had positive perceived severity were 2.65 times more likely to have health care seeking behavior than those women with negative perceived severity towards cervical cancer screening (AOR = 2.65, 95%CI = 1.71-4.09).This finding is supported by studies conducted in Ghana and Johannesburg which demonstrated a significant and positive correlation between perceived severity and screening behavior [20,27].However, a study conducted in Jimma reported that perceived severity was not significantly associated with cervical cancer screening.This might be due to previous traumatic experiences of women regarding cervical cancer or knowing someone who is suffering from the disease.
This study also revealed that there is no association between perceived self-efficacy of women towards cervical cancer screening and health care seeking behavior.Although it is generally stated by different studies and self-efficacy theory of Albert Bandura, about the relationship between positive self-efficacy and the likelihood of behavioral change, this study is in conflict with self-efficacy theory [28].This might be due to the difference in the knowledge level of the women, lack of experience of cervical cancer, and low level of health seeking behavior of the women towards cervical cancer screening.
In the current study, no significant association was found between health care seeking behaviour towards cervical cancer screening and perceived barriers of cervical cancer screening which is in accordance with a study conducted in Ugrachandi Nala, Kavre, Nepal which revealed no significant association between perceived barriers and cervical cancer screening behaviour [10].The possible explanation might be due to the high perceived benefits of the women, which might outwait the perceived barriers towards cervical cancer screening.The more women perceive the benefits of performing cervical cancer, the more she will bypass the barriers, which will prevent her from getting screening services.However, a study conducted in Latin America showed the association between seeking health care and perceived barriers of cervical cancer screening [29].This might be due to the fear of the majority of the women about the test results and the thought that the screening procedure might be painful.Since most women feel uncomfortable with the idea of vaginal examination or 'private parts, embracement might be another possible explanation.

Limitations of the study
Since an interviewer-administered questionnaire was used, there was a possibility of validating what the participant responded, which has the potential to introduce a social desirability bias.Furthermore, because of the nature of the cross-sectional study design, it could be challenging to determine whether outcome or predictor variables come first.The drawback of the health belief model is also a limitation of this study.The study does, however, have certain strengths.The health belief model, which has helped to examine the woman's beliefs in to four categories; perceived benefit, perceived susceptibility, perceived severity, and perceived barriers.This indepth approach examines a woman's beliefs regarding health care seeking behaviour in a more holistic way than any other model.

Conclusion
The prevalence of health care seeking behaviour towards cervical cancer screening was low in the study area.
Respondents' good knowledge, positive perceived susceptibility, positive perceived severity, and positive perceived benefits were significantly associated with health seeking behavior.Women's health care seeking behavior towards cervical cancer screening is maximized by acting on the degree to which the woman feels susceptible to cervical cancer, knowledge regarding cervical cancer and its screening, the degree to which women believe the consequences of cervical cancer will be severe, the benefit the woman will get from cervical cancer screening.

Fig. 2
Fig. 2 Schematic presentation of the sampling procedure for a study on health care seeking behavior towards cervical cancer among 30-49 aged women in Arba Minch town, Southern Ethiopia, 2023

Fig. 3
Fig. 3 Health seeking behaviour of the study participants among 30-49 years women in Arba Minch town, southern Ethiopia, 2023

Table 1
Socio-demographic characteristics of the study participants in Arbaminch town, southern Ethiopia, 2023

Table 3
Constructs of health belief model for the study of health seeking behavior towards cervical cancer screening and associated factors among 30-49years women in Arbaminch Town, southern Ethiopia, 2023

Table 4
Bivariate and Multivariable analysis of factors associated with health care seeking behavior towards cervical cancer screening among women aged 30-49 years and women in Arbaminch Town, southern Ethiopia, 2023 *significantly associated factors, COR: Crude odds ratio, AOR: Adjusted odds ratio, 1 Reference group